The COVID-19 pandemic is rapidly evolving. As more information becomes available, we will provide necessary updates. Please be familiar with your local and state resources, as well as the CDC (www.cdc.org) and the WHO (www.who.org). Any questions, please contact info@aser.org and an ASER COVID-19 Taskforce member will get back to you.

Q: Yes. Chest x-rays are the recommended first line imaging test to evaluate for suspected COVID-19 infection per the American College of Radiology-Appropriateness Criteria for Acute Respiratory Illness (https://www.jacr.org/article/S1546-1440(18)31154-2/abstract). If your hospital has created a prehospital strategy to evaluate patients for COVID, there should be portable chest x-ray capabilities available. You will need to coordinate the technical logistics with the equipment vendor and hospital IT. The x-ray technologists will need personal protective equipment (PPE) and will need to be trained on optimal decontamination strategies for themselves and the equipment.

Hospital: Equipment and Imaging Suite

Q: What precautions are needed for patients who need to be imaged?

A: Patients who are suspected to be infected are typically masked when they arrive in the radiology suite. There may come a time very soon when all patients being imaged in the ED are assumed to be infected. Strategies that have been adopted in radiology departments along the lines of infection containment include having dedicated equipment, having a dedicated x-ray room where the patient enters the room and “hugs” the film cassette for a PA portable, or having portable x-ray and CT equipment in a mobile trailer. These are just a few practices that have been shared. We encourage you to be familiar with your hospital infection control guidelines and stay up to date with CDC and WHO recommendations.

Q: Do you have recommendations for decontaminating (“decon”) a room?

A: As medical resources are overwhelmed by the demand for care, it will be important to consider a rational and ethical approach for meeting those demands. Significant time requirements necessitated by upholding standard of care infection control recommendations may delay appropriate patient care. In the early days of the COVID-19 epidemic, colleagues reported that decon strategies used after a CT study took an 1 hour. Two weeks later, as the number of cases rose, the demand for imaging studies increased, and the need to evaluate more patients faster had to be considered against the standard of care, colleagues started reporting decon procedures taking 15 min following a process that was blessed by hospital infection control. This reflects the adaptations that must occur as a crisis escalates, resources (e.g. time, medication, equipment, supplies) run scarce, and more patients need to be evaluated.

A pro-active, interdepartmental approach to re-defining the standard of medical care for conventional, contingency, and crisis operations is highly advised1. During conventional mass casualty operations, response strategies start with “Conserve” and “Substitute”. These strategies will expand to include “Adapt” and “Re-use” during contingency operations. Finally, care may be “reallocated” from one patient to another during crisis operations. It is imperative that hospital leadership determines what mode the hospital is operating in. ASER recommends early engagement with hospital leadership to address these eventualities.

A: The x-ray technologists need appropriate personal protective equipment and need to be trained on optimal decontamination strategies for themselves and the equipment. There is written and video educational material at the CDC website that demonstrate how to don and doff PPE. Attempts to maintain social distancing should be applied in all situations, especially in confined areas, such as CT control room.

Q: What recommendations do you have to protect our radiologists?

A: Social distancing and minimizing physical contact are critical for preventing spread of the virus. Some recommended strategies include reducing in-person staffing to minimum necessary levels while shifting to remote coverage if possible, adhere to recommendations of maintaining a distance of 6-10 feet, controlling the number of clinicians in the reading room at any given time, and using the same workstation all day.

Radiology Imaging and Protocols:

Q: Is there a CT chest protocol that you would recommend? Recommendations for pared down protocols during surge?

A: It needs to be stated that imaging should not replace clinical screening or preclude laboratory confirmation of the disease. CT should not be used on asymptomatic patients. A negative CT also does not exclude the disease. IV contrast should be used only if absolutely necessary in order to minimize direct contact between the technologist and the patient. IV contrast may be used for assessing complications such as abscess or other diagnoses, e.g. aortic dissection or pulmonary embolus.

For a pared down protocol, a standard noncontrast chest CT, e.g. 3 mm thick slices every 2 mm, should suffice. A dedicated HRCT is unnecessary and reserved for patients with interstitial lung disease. The study can always be reconstructed at thinner slices if necessary. IV contrast should be used if there is concern for a complication such as abscess or other diagnosis, e.g. aortic dissection or pulmonary embolus. For a true surge, where patient volumes far exceed capacity, a further pared protocol designed solely to say YES or NO for CT changes could consist of 5 mm thickness at 10 mm. At one site, a protocol of 5 mm at 15 mm was acceptable to the pulmonologists and emergency physicians.

Radiology Findings:

Q: What are the imaging findings in COVID-19 infection?

A: Many excellent resources are available for radiologists to familiarize themselves with the spectrum of imaging findings in COVID-19 infection and the scientific literature on the test performance of CT. Check out these websites:

Q. Do you have recommendations for reporting? How to manage reporting during a surge?

A. Clear and consistent radiology reporting is absolutely necessary to prevent confusion and misinformation. Appropriate findings can be reported as concerning for viral pneumonia, with other diagnoses included as necessary. In the setting of a surge and high disease prevalence, stronger language can be adopted when index of suspicion is high.